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Closing the drug-resistant tuberculosis treatment gap: Operationalizing the South Africa Policy Framework on Decentralised and De-institutionalised Management of Multidrug-Resistant TB in eThekwini District, KwaZulu-Natal

Closing the drug-resistant tuberculosis treatment gap
Publication date: 
Nov 2019

Background and challenges to implementation  

South Africa diagnoses approximately 20,000 patients with Rifampicin-resistant (RR) tuberculosis (TB) annually. Routine data suggests a large proportion do not receive adequate treatment and likely contribute to drug-resistant TB (DR-TB) transmission. A key contributor to this treatment gap is physical inaccessibility to limited DR-TB treatment facilities. Systems issues such as poor reporting and human resources capacity challenges also contribute. South Africa adopted a DR-TB decentralisation and deinstitutionalisation policy to facilitate access to treatment and address the treatment gap..


To support implementation of the policy, USAID TB South Africa Project facilitated decentralisation of services to 14 of 18 government-identified DR-TB facilities in eThekwini district, KwaZulu-Natal province. DR-TB management teams were established in each based on identified critical health systems gaps. Facility-specific DR-TB packages, including in-service training and clinical systems mentorship support focusing on teams and individual providers were implemented at each site. Mentorship ensured that bi-directional referral pathways were functional and continuous quality improvement methodologies implemented. Reporting systems were established, including activation of electronic TB registers; the EDRWeb. Regular review forums were initiated.


Between October and December 2018, from a zero-baseline, 142 (31%) of all 538 patients initiated on DR-TB treatment were seen at project-supported decentralized sites. On follow-up at six months, 139 (98%) patients were still retained on treatment. Follow-up clinical and chart audits found 100% continued adherence to DR-TB guidelines and 92% overall achievement on data quality audits among health care workers.

Conclusion and recommendations

Despite the limited intervention period, data indicates effectiveness of the decentralisation policy in closing treatment gaps for DR-TB patients. Interventions to expand access to treatment in high-burden and resource limited settings is essential. However, focusing on treatment alone is insufficient; targeted clinical systems mentorship is a prerequisite for expansion, quality and effective linkage of patients to treatment services.